Roula K. Sweis M.A., Psy.D

Supervisory Program Advisor

HUD’s Office of the Assistant Secretary for

Community Planning and Development

HUD’s H² TA Initiative: A Framework for Understanding Healthcare and Facilitating Action

Fiscal Year 2014 CoC Awards

$1,361,841,539

$448,718,455 Balance of Award

Supportive Services

75%

Nation-Wide = $1,810,559,994

25%

Eligible Costs – Supportive

Services

• Assessing service needs

• Moving costs

• Case management

• Child care

• Education services

• Employment assistance & job

training

• Food

• Housing search & counseling

services

• Legal services

• Life skills training

• Mental health services

• Outpatient health services

• Outreach services

• Substance abuse treatment

services

• Transportation

• Utility Deposits

In general, grant funds may be used on those services listed in the CoC Program interim rule only

HUD – CMS Collaboration HUD-Funded Supportive Service

HUD Description of HUD-Funded Supportive Service

Medicaid Authority Medicaid Citation/Source

Case Management

The costs of assessing, arranging, coordinating,

and monitoring the delivery of individualized

services to meet the needs of the program

participant(s) are eligible costs…including

planning a path to permanent housing stability.

Case Management under

1. Optional State Plan Services

A. Targeted Case Management

B. Community First Choice

C. State Plan HCBS1

2. Waivers

A. HCBS Waiver2

B. 1115 Waiver

For Targeted Case Management (TCM)

42CFR 440.169

For Community First Choice 42CFR

441.500

For State Plan HCBS 42CFR 440.182

For HCBS Waivers 42CFR 440.180

For 1115 Waiver Social Security Act Sec

1115

Life Skills

The costs of teaching critical life management

skills that may never have been learned or have

been lost during the course of physical or mental

illness, domestic violence, substance abuse, and

homelessness are eligible…

1. Optional State Plan Services

A. Rehabilitation

B. Clinical Social Worker

2. Waivers

A. HCBS Waiver

B. 1115 Waiver

For Rehab 42 CFR 440.130(d)

For Clinical Social Worker 42CFR440.60

For HCBS Waivers 42CFR 440.180

For 1115 Waiver Social Security Act Sec

1115

Mental Health Services

Eligible costs are the direct outpatient treatment of

mental health conditions that are provided by

licensed professionals. Component services are

crisis interventions; counseling; individual, family,

or group therapy sessions; the prescription of

psychotropic medications or explanations about the

use and management of medications; and

combinations of therapeutic approaches to address

multiple problems.

Behavioral Health:

1. State Plan Services

Psychiatry

2. Optional State Plan Services

A. Psychologist

B. Rehabilitation

C. Clinic services

D.Clinical Social Worker

E. State Plan HCBS

2. Waivers

A. HCBS Waiver

B. 1115 Waiver

For Psychiatrist- 42CFR440.50

For Psychologist 42CFR440.60

For Rehab 42 CFR 440.130(d)

For Clinic Services 42CFR 440.90

For Clinical Social Worker 42CFR440.60

For State Plan HCBS 42CFR 440.182

For HCBS Waivers 42CFR 440.180

For 1115 Waiver Social Security Act Sec

1115

1 Home and Community Based Services

2 Eligibility for this authority includes meeting medical necessity for Medicaid institutional care in the State. In states using managed care to provide Long Term

Supports and Services the HCBS waiver is combined with a 1915(b) waiver to allow HCBS to be provided by a Managed Care Organization

Analysis of CoC Application Question

Analysis of CoC Application Question

Analysis of CoC Application Question

Overview of the H² TA Approach

1. Data Analysis Identified Gaps and Challenges

2. Gaps and Challenges 5 Pronged TA Proposal

3. Consultations on Proposal Finalized TA and Built Coalition

4. Implementation Constant Feedback Loop and Refinement

H² Coalition of Federal Partners

H² - A 5 Pronged TA Initiative

1. Listserv Messages and ACA Website Enhancement 2. Webinars 3. Homeless & Healthcare Systems Integration Action Planning Sessions 4. Assessment (Case studies/tools and products for widespread dissemination) 5. Health Insurance Data Collection & Quality Improvement

Outreach Checklist

Federal Agencies HUD Field Office Directors HRSA Regional Administrator SAMHSA Regional Administrator USICH Regional Coordinator Housing CoC Coordinator PSH Providers Other Housing Providers in CoC Supportive Service Providers HOPWA/Ryan White Providers HMIS administrators Healthcare FQHCs Healthcare for the Homeless Programs Hospital and medical facilities

Mental Health/Behavioral Health agencies Managed Care Organizations Primary Care Association SAMHSA Grantees Center for Substance Abuse Treatment

(CSAT) Grantees Center for Mental Health Services

(CMHS) Grantees Insurance State Medicaid Program County/Local Health Plans (if applicable) Centers for Consumer Information and

Insurance Oversight (CCIIO) Grantees Funding Programs Foundations

Structure the Conversation

Five Healthcare Related Model Strategies to Consider in Developing an Action Plan:

1. Enrollment

2. Access

3. Integration

4. Data

5. Resource Maximization

Structure the Conversation

Enrollment: Facilitate enrollment of people who are homeless and at-risk in Medicaid;

Promote client awareness about expanded eligibility requirements and enrollment resources

Identify clients in need of enrollment or renewal assistance

Assist uninsured clients with enrollment

Advocate for enrollment procedures that facilitate homeless enrollment

Structure the Conversation

Access

Facilitate access to services and effective management of health conditions – expand or transform existing activity and/or initiate new efforts

Reduce inappropriate use of costly emergency and inpatient services

Structure the Conversation

Integration

Build capacity for integrating health, behavioral health, housing and social services for homeless persons with multiple needs

Integrate data across homeless, health care and other systems to provide a comprehensive overview of needs

Structure the Conversation

Data

Promote State and County level action to facilitate adequate Medicaid reimbursement for medical and support services that promote stable housing and ongoing wellness

Develop and transform agency structures and operations to enable Medicaid billing

Explore/Pilot different Medicaid payment models for services provided by homeless housing and service providers]

Identify other sources of funding for essential services not eligible for Medicaid reimbursement

Framework Used to Structure Events

Cross-Cutting Issues to be considered as part of the implementation:

1. Training: What training will be needed for staff? 2. Partnerships: What partnerships are needed and how

can they be forged? 3. Targeting: Should particular sub-populations be targeted

and how should they be identified? 4. Scale: What will be needed to bring the strategy to a

scale appropriate to meet the need? 5. Systems: How can individual programmatic efforts be

aligned into a unified system working toward shared outcomes?

What has Worked

Federal partners at the table and behind the scenes

Early outreach and purpose/goal setting

Linkage to HUD policy priorities and budget efficiency

Transparency (website)

Using systematic processes and methods

Engagement – minimal didactic methods, majority of time spent interacting with material and other participants

What has Worked Administrative/Leadership Levels:

Structural

Policy

Region

Integration/Coordination Approaches:

Cross-system coalitions

Recuperative care programs

Linkages between and to Coordinated Entry (FQHCs, HCH, ERs, MCOs, CoCs, Shelters)

Re-cast homelessness as public health issue

Co-location strategies

What has Worked

Data

Ensure hospitals are using ICD codes that relate to homelessness and housing stability

Compare cross-system data to identify individual who come into contact with multiple systems or frequently receive high-cost services

Maximizing Medicaid and Other Resources

Conduct review of State Medicaid Plan Increase use of SOAR Train charting staff at hospitals to properly document

disabilities Work with PHAs to create preferences or set-asides for

chronically homeless.

CMCS Informational Bulletin – 6/26/2015

“Coverage of Housing-Related Activities and Services for Individuals with Disabilities”

Assist states in designing Medicaid benefits;

Clarify circumstances under which Medicaid reimburses for certain housing-related activities;

Goal is to promote community integration for: Individuals with disabilities;

Older adults needing LTSS

Those experiencing chronic homelessness

Found Here

What has Been Challenging

Partnership requires:

Extensive relationship building;

Negotiating and influencing; and

Effective engagement strategies

Flexibility. Culture Change – Homeless Assistance and Healthcare

Navigating Medicaid opportunities in local context

Limited resources, especially human capital at federal level

Resources HUD https://www.hudexchange.info/aca/ CMS Medicaid and Chip basics: www.insurekidsnow.gov Supporting enrollment efforts: http://www.medicaid.gov/medicaid-chip-program-information/by-

topics/outreach-tools/supporting-enrollment-efforts/supporting-enrollment-efforts.html ASPE Let’s Get Everyone Covered: http://www.hcd.ca.gov/LetsGetEveryoneCovered.pdf HRSA Find a health center: http://findahealthcenter.hrsa.gov SAMHSA Homeless and Housing Resource Network (HHRN): http://homeless.samhsa.gov/ SOAR works: http://soarworks.prainc.com/ Administration for Children and Families: Information on youth accessing healthcare: http://www.acf.hhs.gov/programs/fysb/resource/getting-taken-

care-of-20140912

Resources (Cont.)

National Health Care for the Homeless Council NHCHC outreach information: https://www.nhchc.org/resources/clinical/tools-and-

support/outreach/ NHCHC enrollment toolkit: https://www.nhchc.org/policy-advocacy/reform/nhchc-health-

reform-materials/ NHCHC training website: https://www.nhchc.org/training-technical-assistance/request-

training-or-ta/ NHCHC website including policy briefs: https://www.nhchc.org/policy-

advocacy/reform/nhchc-health-reform-materials/ Families USA State private insurance checklist: http://familiesusa.org/product/private-insurance-

advocacy-checklist-getting-know-your-states-health-insurance-landscape Medicaid Expansion helps low-wage workers: http://familiesusa.org/product/medicaid-

expansion-helps-low-wage-workers

Questions/Comments

Roula K. Sweis

HUD – Community Planning and Development

Supervisory Program Advisor

Roula.k.sweis@hud.gov

202-402-5645